FY22.23-Q4 FRHD Community Health Contract Grant Impact Report

1

Organization InformationPlease provide the legal name of the organization, as it appears on your 990. If you have a different DBA or nickname please add that in the box adjacent to the legal name.

Legal Name

DBA (if Applicable)

2

Program Name/Title* This field is required.

3

Contact Information* This field is required.Please add the contact information for the person responsible for the submission and monitoring of this grant application.

Contact Name

Title

Primary Contact Phone

Email Address

4

Organization Mailing Address* This field is required.This addressed will be used for all mailing purposes.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

5

Organization Physical Address* This field is required.This is the primary address where the Organization provides services.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

6

Total number of residents that benefited (participant/client) from this program this quarter.* This field is required.The number of residents that receive the service or who are enrolled in your program.

7

Target Population - Age* This field is required.List the percentages of your program participants’ ages. Percentages must add up to 100%

Percent of program participants

Total Number of Participants

Children (infants to 12)

Young Adults (13-17)

Adults (18-60)

Seniors (60+)

We do not collect this data (indicate with 100%)*

Children (infants to 12)

Young Adults (13-17)

Adults (18-60)

Seniors (60+)

We do not collect this data (indicate with 100%)*

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

8

Target Population not collected - AgeIf you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question does not apply to your organization

0/200

9

Target Population - Gender* This field is required.List the percentages of your program participants’ gender identification. Percentages must add up to 100%

Percent of program participants

Total Number of Participants

Female

Male

Non-binary

Unknown*

Female

Male

Non-binary

Unknown*

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

10

*Target Population - GenderIf you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question does not apply to your organization

0/200

11

Target Population - Income Level* This field is required.List the percentages of your program participants' income limit category - 2019 HUD – AMI Income limits (4 person family). Percentages must add up to 100%

Percent of program participants

Total Number of Participants

Extremely Low-Income Limits, ceiling of $32,100

Very Low (50%) Income Limits, ceiling of $53,500

Low (80%) Income Limits, ceiling of $85,600

Higher Than Listed Limits

We do not collect this data (indicate with 100%)*

Extremely Low-Income Limits, ceiling of $32,100

Very Low (50%) Income Limits, ceiling of $53,500

Low (80%) Income Limits, ceiling of $85,600

Higher Than Listed Limits

We do not collect this data (indicate with 100%)*

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

Percent of program participants

Total Number of Participants

12

*Target Population - Income LevelIf you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question does not apply to your organization

0/300

13

Program/Services Description - Social Determinants of Health* This field is required.Please select which of the following SDOH your program addresses.

Economic Stability (Employment, Food Insecurity, Housing Instability, Poverty)

Education Access & Quality (Early Childhood Education and Development, Enrollment in Higher Education, High School Graduation, Language and Literacy)

Social & Community Context (Civic Participation, Discrimination, Incarceration, Social Cohesion)

Healthcare Access & Quality (Access to Health Care, Access to Primary Care, Health Literacy)

Neighborhood & Built Environment (Access to Foods that Support Healthy Eating Patterns, Crime and Violence, Environmental Conditions, Quality of Housing)

14

Program/Services Description - FRHD Community Needs Assessment* This field is required.Please select which of the following identified community needs your program addresses.

Health (Diabetes - prevention, management)

Health (Cholesterol, High Blood Pressure, Hypertension, Obesity)

Mental Health (Social Support - Youth or Families)

Mental Health (Screenings, Prevention)

Health (Mobility)

Health (Age Related Deficits)

Health (Healthy Food/Nutrition)

Social (Economic Security, Health Literacy, Family/Child Support, Legal/Advocacy)

This program does not directly address any of the above with measurable outcomes.

15

Program Objectives* This field is required.Please list the objectives you submitted with this application. You will be expected to answer the following questions in reference and order to these objectives. Please do not use bullets or special formatting.

16

Program Outcomes/Measurables* This field is required.Define the measurable activities and outcomes the program generates for each objective stated in the preceding question. Provide the data or information you gather as it relates to the impact of your program's services. Please do not use bullets or special formatting.

0/250

17

FRHD Grant Support Acknowledgment* This field is required.Please select the methods by which the Organization acknowledged the District's grant funding investment.

Social Media Postings

Signage at Service Sites

Print Materials to Service Recipients

Website Display

Other

18

FRHD Grant Support Acknowledgment* This field is required.Please describe how the Fallbrook Regional Health District’s investment in this program was acknowledged. This includes all print and electronic materials, press releases, website references, and any other form of written and verbal publicity that relates to the funded program. Please do not use bullets or special formatting.

0/250

19

Please provide an example of how the District's grant funding was acknowledged.* This field is required.Copy of social media post, media ad, or other as described above.

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Max. file size: 10.6MB

20

Program Budget* This field is required.Please upload the Program Budget you submitted with the grant application. The 5th tab or FRHD CHC GRANT BUDGET REPORTING FORM should be completed each quarter.

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Max. file size: 10.6MB

21

Impact Story* This field is required.Please upload an Impact Story that demonstrates how the FRHD-CHC grant funds provided benefit to a resident of the District. Please provide a photo whenever possible. Note that this story and photo may be used by the District in our social media or other print materials to demonstrate how resident's tax dollars are invested in local programming.

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Max. file size: 10.6MB

22

Opportunities & ChallengesPlease describe any unforeseen opportunities or challenges that were presented in this last quarter.